Ensuring Progress Toward Ending the HIV Epidemic While Confronting the Dual Pandemics of COVID-19 and Systemic Racism

In early 2019, the Trump administration announced Ending the HIV Epidemic: A Plan for America (EHE) with the ambitious goal of ending the HIV epidemic in the United States by 2030.¹ The plan, modeled after several other jurisdictional initiatives, focuses on four main pillars: HIV prevention, diagnosis, treatment, and outbreak response. Before the COVID-19 pandemic, the overall number of new HIV diagnoses in the United States had been declining yearly; however, new diagnoses among Black and Latinx men who have sex with men and transgender women had plateaued and, in some cases, increased.² The current pandemic has the potential to reverse hard-fought progress toward ending the HIV epidemic as well as worsen existing HIV-related inequities. At the same time, entrenched systemic racism, if not addressed, remains a potent barrier to ultimately ending the HIV epidemic. The pandemic, along with the recent killings of Black people by police and subsequent social uprisings, have increased attention to systemic racism and magnified persistent health inequities, compelling dozens of states and local jurisdictions to declare racism a public health issue.³ As we grapple with the dual pandemics of COVID-19 and systemic racism, the following recommendations may help to ensure continued progress toward EHE’s goal.

First, although health care for all should, undoubtedly, be an ultimate goal, short of that, implementing Medicaid expansion in states that have yet to do so would help to advance EHE’s goal. As of June 2021, 39 states had adopted Medicaid expansion under the Affordable Care Act (ACA).⁴ The ACA has led to an increase in the number of people with HIV (PWH) who are insured, a change driven primarily by Medicaid expansion.⁵ Repeal of the ACA or substantive changes to its key provisions by the Supreme Court would undoubtedly undo these gains and doom EHE. The South, the current epicenter of the HIV epidemic in the United States, has been hit hard by COVID-19. Yet, many Southern states still have not adopted Medicaid expansion.⁴

Unsurprisingly, the very same populations at risk for HIV and COVID-19 are more likely to be uninsured. In particular, queer and transgender people of color have been more likely to lose jobs during the pandemic, which often translates to loss of employer-based health insurance.⁶ This coupled with impending mass evictions places many Americans, especially those who are Black and Latinx, at risk for poor HIV- and COVID-19–related health outcomes. Medical mistrust, the current political climate, and concerns about the public charge rule make it less likely that uninsured or underinsured people, especially immigrants, will access HIV and sexual health services. Comprehensive health coverage such as Medicaid would help to ensure that PWH and those at risk have ready access to HIV prevention and treatment services.

Second, to reach communities most affected by HIV, we must implement innovative approaches that use partnerships with community-based organizations (CBOs) that are uniquely poised to reach those most in need. HIV testing is the gateway to HIV prevention and treatment; however, physical distancing requirements during the COVID-19 pandemic limited the ability of many CBOs to reach clients. During my time leading the New York City Health Department’s Bureau of HIV, we launched a successful program to provide free home delivery of HIV self-test kits. The program built on existing relationships with clinical and nonclinical CBOs. The same approach could be used for home-based testing for other sexually transmitted infections and hepatitis C. CBOs should be involved in COVID-19–related public health efforts, including educating community members about prevention, testing, contract-tracing efforts, and available resources in a structurally competent manner. In so doing, CBOs can also help to address mistrust, misinformation, and concerns regarding the public charge rule, stigma, and even a potential vaccine.

Third, EHE funding must directly support housing and employment opportunities for PWH and persons at risk. Several federal programs offer funding for PWH to secure safe, stable housing, including the Department of Housing and Urban Development’s Housing Opportunities for Persons with AIDS program and the Health Services and Resources Administration’s Ryan White HIV/AIDS Program (RWHAP). Earlier in the pandemic, RWHAPs across the United States received supplemental funding under the Coronavirus Aid, Relief, and Economic Security Act; in New York City, we used part of our award for short-term rental assistance and housing programs and emergency financial assistance for RWHAP clients. Given the massive job losses and impending evictions owing to the pandemic and preexisting affordable housing crisis, enhanced funding to address employment and housing needs as well as other social determinants of health (e.g., food insecurity) would help to ensure EHE’s success. Such an effort would require coordination across multiple executive branch agencies and could be bolstered by a presidential memorandum similar to the one issued by President Obama at the launch of the National HIV/AIDS Strategy in 2010, which mandated that these agencies work in a coordinated fashion to address the structural and social factors most affecting PWH and persons at risk.⁷

Lastly, and perhaps, most importantly, systemic racism, a potent driver of HIV and COVID-19 inequities, must be explicitly called out and addressed. Notably, in the EHE plan, there is a lack of focus and attention to addressing the structural factors, such as racism and other systems of oppression, that drive HIV-related inequities. In response, the Black AIDS Institute issued We the People: A Black Plan to End HIV, which calls for dismantling racist policies and practices that negatively affect the health of Black communities and for investing in resources to mitigate the social and structural factors that worsen health outcomes in Black communities.⁸

In the spirit of the Black AIDS Institute’s plan, the Biden administration has the opportunity to provide substantial new EHE funding to support efforts to dismantle structural racism in HIV prevention and treatment programs, surveillance, and research. This investment could include financial support for the development, retention, and advancement of Black and Latinx leadership within the HIV arena; for Black and Latinx-led and -serving grassroots CBOs, many of which have been indispensable partners in working to end the HIV epidemic; and for the development of equity-focused metrics, such as the Bureau of HIV’s pre-exposure prophylaxis equity index and systems to track and respond meaningfully to these metrics.⁹ EHE funding to jurisdictions could be made contingent, in part, on their developing plans to address structural racism within their own organizations and in their engagement with the communities they serve. In this same vein, the New York City Health Department has had success with implementing agency-wide health equity training for its staff, offering antiracism training to RWHAP community-based providers, and using tools such as the Government Alliance on Race and Equity’s Racial Equity toolkit to help operationalize racial equity.¹⁰

The COVID-19 pandemic and increased attention to systemic racism’s impact on health have brought a new sense of urgency to ending the HIV epidemic. Although new tools such as long-acting HIV treatment and pre-exposure prophylaxis are on the horizon and have the potential to transform the epidemic, they are insufficient without meaningful policy change. To help reach EHE’s goal, we must ensure a health care safety net for the most vulnerable, use partnerships with grassroots CBOs, create meaningful housing and employment opportunities, and work toward dismantling systemic racism.